Method and apparatus for attaching soft tissue to bone

ABSTRACT

A method and apparatus for securing soft tissue to bone can include forming a bore in the bone and carrying a flexible suture anchor into the bore. The flexible anchor can include a passage and can be coupled to a suture construct. The suture construct can include at least one self-locking adjustable loop, and the flexible anchor can include a first profile while being carried into the bore. A shape of the flexible anchor can be changed from the first profile to a second profile forming an anchoring mass to retain the flexible anchor in the bore. Tension can be applied to a portion of the suture construct to reduce a size of the self-locking adjustable loop and secure the soft tissue relative to the flexible anchor and the bone.

CROSS-RELATED APPLICATIONS

This application is a divisional of U.S. patent application Ser. No. 12/915,962 filed on Oct. 29, 2010, now U.S. Pat. No. 8,562,647 issued on Oct. 22, 2013, which is a continuation-in-part of U.S. patent application Ser. No. 12/719,337 filed on Mar. 8, 2010, now U.S. Pat. No. 9,078,644 issued on Jul. 14, 2015, which is a continuation-in-part of U.S. patent application Ser. No. 12/489,168 filed on Jun. 22, 2009, now U.S. Pat. No. 8,361,113 issued on Jan, 29, 2013, which is a continuation-in-part of U.S. patent application Ser. No. 12/474,802 filed on May 29, 2009, now U.S. Pat. No. 8,088,130 issued on Jan. 3, 2012, which is a continuation-in-part of (a) U.S. patent application Ser. No. 12/196,405 filed on Aug. 22, 2008, now U.S. Pat. No. 8,128,658 issued on Mar. 6, 2012; (b) U.S. patent application Ser. No. 12/196,407 filed on Aug. 22, 2008, now U.S. Pat. No. 8,137,382 issued on Mar. 20, 2012; (c) U.S. patent application Ser. No. 12/196,410 filed on Aug. 22, 2008, now U.S. Pat. No. 8,118,836 issued on Feb. 21, 2012; and (d) U.S. patent application Ser. No. 11/541,506 filed on Sep. 29, 2006, now U.S. Pat. No. 7,601,165 issued on Oct. 13, 2009.

This application is a continuation-in-part of U.S. patent application Ser. No. 13/645,964 filed on Oct. 5, 2012, which is a divisional of U.S. patent application Ser. No. 12/570,854 filed on Sep. 30, 2009, now U.S. Pat No. 8,303,604 issued on Nov. 6, 2012, which is a continuation-in-part of U.S. patent application Ser. No. 12/014,399 filed on Jan. 15, 2008, now U.S. Pat. No. 7,909,851 issued on Mar. 22, 2011.

This application is a continuation-in-part of U.S. patent application Ser. No. 12/702,067 filed on Feb. 8, 2010, now U.S. Pat. No. 8,562,647 issued on Mar. 18, 2014, which is a continuation of U.S. patent application Ser. No. 11/541,505 filed on Sep. 29, 2006, now U.S. Pat. No. 7,658,751 issued on Feb. 9, 2010.

This application is a continuation-in-part of U.S. patent application Ser. No. 13/098,927 filed May 2, 2011, now U.S. Pat. No. 8,652,171 issued on Feb. 18, 2014, which is a continuation-in-part of U.S. patent application Ser. No. 12/196,398 filed Aug. 22, 2008, now U.S. Pat. No. 7,959,650 issued on Jun. 14, 2011, which is a continuation-in-part of U.S. patent application Ser. No. 11/784,821 filed Apr. 10, 2007.

The disclosures of all of the above applications are incorporated by reference herein.

FIELD

The present disclosure relates generally to a method and apparatus for attaching soft tissue to bone.

BACKGROUND

The statements in this section merely provide background information related to the present disclosure and may not constitute prior art.

Tears caused by trauma or disease in soft tissue, such as cartilage, ligament, or muscle, can be repaired by suturing. Various repair techniques and devices have been developed for facilitating suturing that include the use of rigid, non-flexible anchors and that are effective for their intended purposes. Nevertheless, there is still a need in the relevant art for tissue repair techniques and associated devices for facilitating suturing without requiring the use of rigid anchors.

SUMMARY

This section provides a general summary of the disclosure, and is not a comprehensive disclosure of its full scope or all of its features.

In one form, the present disclosure provides a method for securing soft tissue to bone. The method can include forming a bore in the bone and carrying a flexible anchor into the bore. The flexible anchor can include a passage and can be coupled to a suture construct. The suture construct can include at least one self-locking adjustable loop, and the flexible anchor can include a first profile while being carried into the bore. The method can close include changing a shape of the flexible anchor from the first profile to a second profile forming an anchoring mass to retain the flexible anchor in the bore. Tension can be applied to a portion of the suture construct to reduce a size of the self-locking adjustable loop and secure the soft tissue relative to the flexible anchor and the bone.

In another form, the present disclosure provides a method for securing soft tissue to bone. The method can include forming a bore in the bone and forming a suture construct. Forming the suture construct can include providing a suture having a first and second free ends and a body defining a passage portion; providing first and second flexible suture anchors each having a passage; coupling the first and second anchors to the suture by passing a portion of the suture through a portion of the passage of each flexible anchor; and passing the first and second free ends of the suture into and through the passage portion in opposite directions to form first and second self-locking adjustable loops. The method can also include carrying the first flexible suture anchor into the bore where the flexible anchor includes a first profile while being carried into the bore, and changing a shape of the first flexible anchor from the first profile to a second profile forming an anchoring mass to retain the flexible anchor in the bore. Tension can be applied to the first and second ends of the suture construct to reduce a size of the first and second self-locking adjustable loops and secure the soft tissue relative to the first flexible anchor and the bone.

In yet another form, the present disclosure provides an assembly for securing soft tissue to bone. The assembly can include a flexible tubular anchor having a passage and a flexible member construct. The flexible member construct can include a body defining a passage portion between first and second ends, where the first end can be passed though a portion of the passage of the flexible tubular anchor that is spaced apart from respective ends of the flexible anchor. The first end can also be passed into and through the passage portion via first and second openings associated with the passage portion to form at least one adjustable, self-locking loop. The flexible anchor can be slidably coupled to the flexible member construct and can be configured to be collapsible upon engagement with bone to form an anchoring mass having a locking profile.

Further areas of applicability will become apparent from the description provided herein. It should be understood that the description and specific examples are intended for purposes of illustration only and are not intended to limit the scope of the present disclosure.

DRAWINGS

The present disclosure will become more fully understood from the detailed description, the appended claims and the following drawings. The drawings are for illustrative purposes only and are not intended to limit the scope of the present disclosure.

FIG. 1 is a perspective view of an exemplary shoulder labral tear and a partial view of an exemplary guide instrument according to the present disclosure;

FIG. 2 is an exemplary view of a portion of the glenoid bone with the torn labrum shifted away from a rim of the glenoid by a portion of the exemplary guide instrument according to the present disclosure;

FIG. 3 is a view, partially in section, of an exemplary labral repair surgical technique using the exemplary guide instrument and an exemplary drill;

FIG. 4 is a side view of an exemplary inserter instrument with an exemplary suture and flexible anchor coupled thereto according to the present disclosure;

FIG. 5 is a perspective view of an exemplary flexible anchor slidably coupled to a suture according to the present disclosure;

FIG. 6 is a perspective view of the exemplary surgical technique depicting the inserter slidably positioned in the guide instrument and impacted to drive the flexible anchor into a bore drilled in the glenoid bone;

FIG. 7 is a partial side view of the exemplary surgical technique, inserter and guide instrument of FIG. 6;

FIG. 8 is a partial sectional view of the exemplary surgical technique, inserter and guide instrument of FIG. 6 showing the flexible anchor driven into a bore drilled in the glenoid bone;

FIGS. 9A and 9B are sectional views of the exemplary surgical technique depicting the flexible anchor being deployed from the inserter according to the present disclosure;

FIG. 10 is a partial perspective view of the exemplary surgical technique depicting portions of the suture being decoupled from the inserter according to the present disclosure;

FIG. 11 is a sectional view of the exemplary surgical technique depicting portions of the suture being pulled or tightened to secure the flexible anchor in the bore according to the present disclosure;

FIG. 12 is a perspective view of the exemplary surgical technique depicting multiple anchors being used to secure the labral tear using a sliding knot according to the present disclosure;

FIGS. 13, 14 and 15 are views of exemplary suture constructs with flexible anchors according to the present disclosure;

FIG. 16 is a perspective view of an exemplary alternative inserter instrument according to the present disclosure;

FIG. 17 is a side view of the inserter of FIG. 16 with an exemplary suture construct coupled thereto according to the present disclosure;

FIG. 18 is a top view of a portion of the inserter of FIG. 16 according to the present disclosure;

FIG. 19 is a side view of the portion of the inserter of FIG. 18 according to the present disclosure;

FIG. 20 is a sectional view of an exemplary surgical technique for the shoulder labral tear using an exemplary suture construct positioned over at least a portion of the labrum according to the present disclosure;

FIG. 21 is a side view of the inserter of FIG. 4 with an exemplary suture construct coupled thereto according to the present disclosure;

FIG. 22 is a sectional view of an exemplary surgical technique for the shoulder labral tear using an exemplary suture construct extending through a portion of the labrum according to the present disclosure; and

FIG. 23 is a view of an exemplary surgical technique for a facelift according to the present disclosure.

DETAILED DESCRIPTION

The following description is merely exemplary in nature and is not intended to limit the present disclosure, its application, or uses. It should be understood that throughout the drawings, corresponding reference numerals indicate like or corresponding parts and features. Although the following description is related generally to instruments, sutures and suture constructs using flexible anchors in connection with a shoulder labral repair technique, it will be understood that the devices and methods discussed herein can also be applicable to other appropriate surgical procedures, such as, for example, a facelift procedure or a labral tear in a hip joint. Therefore, it will be understood that the following discussions are not intended to limit the scope of the present teachings or claims herein.

With initial reference to FIGS. 1-12, various methods and apparatus are disclosed according to the present teachings for attaching soft tissue to bone, and more particularly for treating a labral tear associated with a shoulder joint. With particular reference to FIG. 1, a portion of an exemplary shoulder joint 10 is shown with a glenoid 14 and a labrum 18 attached thereto. The illustrated shoulder joint 10 includes an exemplary labral tear 22, such as a Bankart labral tear, where a portion of the labrum 18 has been separated from a surface 26 of the glenoid 14.

Continuing with FIGS. 2-12, an exemplary method of repairing labral tear 22 along with exemplary instruments and suture constructs will now be discussed. Once the labral tear 22 has been identified, the portion of the labrum 18 associated with labral tear 22 can be held away or positioned offset from the glenoid surface 26 to expose the underlying bone surface where the labrum 18 will be attached. The bone surface can be prepared as bleeding bone surface with any appropriate tool, such as a rasp (not shown). The labrum 18 can be held away from surface 26 with a guide instrument 30 (FIGS. 2 and 3) or any other appropriate instrument. Guide instrument 30 can include a proximal handle 34 and an elongated cannulated guide member 38 extending from handle 34 to a distal tip 42. The handle 34 can include a first end 46, a second opposite end 50 and an internal bore 54 aligned with guide member 38. Guide member 38 can be configured to guide a drill bit and inserter instrument, as will be discussed herein. A sight window 58 can be provided in a distal end 62 of the guide member 38 adjacent the distal tip 42, as shown for example in FIG. 3.

The distal tip 42 of guide 30 can be positioned on prepared surface 26, as generally shown in FIGS. 2 and 3. Distal tip 42 can include a recess or U-shaped configuration 44 (FIG. 1) to aid in preventing slipping relative to the bone. Once positioned, a drill bit 70 coupled to a drill or driver 74 can be inserted into cannulated guide member 38 to drill a bore 78 in the glenoid bone 14 for receipt of a flexible anchor, as will be discussed in greater detail below. Drill bit 70 can be appropriately sized relative to a length of guide 30 so that a specific length bore can be drilled into the glenoid 14. In particular, the drill can be advanced relative to guide 30 until a chuck or collar 82 of drill 74 contacts first end 46 of handle 34. In this regard, various drill bits having different lengths can be provided for selection by a surgeon to drill an appropriate length bore in the glenoid of a patient. Upon drilling bore 78, drill 74 and bit 70 can be removed from guide 30 while maintaining guide 30 in the same position over bore 78.

Referring to FIG. 4, an exemplary inserter instrument 86 can be provided to facilitate implanting various suture constructs into a prepared bore in the anatomy, such as bore 78. Inserter 86 can include a handle 90 and an elongate inserter member 94 extending therefrom along a longitudinal axis of the instrument. Handle 90 can include a first end 98, a second end 104 and lateral sides 108. One or both lateral sides 108 can include a longitudinal recess or channel 112 extending along at least a portion of a longitudinal length of handle 90, as also shown in FIG. 4. A protrusion 118 can extend vertically from a top surface 122 of handle 90 or perpendicular to the longitudinal axis and can include a slot or opening 126 on a side 110 of handle 90 having longitudinal channel 112, which slot 126 communicates with channel 112. A cap or securing member 134 can be coupled to handle 90 via strap 138 and can be configured to removably engage protrusion 118 to secure a suture construct to the handle, as will be discussed herein. Handle 90 can also include an appropriately sized projection 144 to facilitate removably coupling securing member 134 to handle 90 when the securing member is not coupled to protrusion 118. In other words, securing member 134 can be pressed onto projection 144 to retain the securing member against handle 90 when not coupled to protrusion 118. In one exemplary configuration, such as the configuration shown in FIG. 4, the protrusion 118 and securing member 134 can include a Luer Lock arrangement or other quick release coupling arrangements.

Elongate member 94 can extend from second end 104 and can include a terminal or distal tip 146 having a forked configuration 148 sized and shaped to removably receive a flexible anchor 150, as shown in FIG. 4. Flexible anchor 150 can be an elongate member having a sleeve or tubular configuration with first and second ends 154, 158 and an internal passage 162 extending therebetween, as shown in FIG. 5. The flexible anchor 150 can be made of resorbable or non-resorbable materials, including braided suture, sponges and sponge-like materials in solid form, perforated materials, woven/braided from biocompatible materials or fibers, such as, for example, polymer, polyester, polyethylene, cotton, silk, or other natural or synthetic materials.

The flexible anchor 150 can have any properties that allow the flexible anchor 150 to change shape. In this regard, the flexible anchor 150 can be, for example, compliant, flexible, foldable, squashable, squeezable, deformable, limp, flaccid, elastic, low-modulus, soft, spongy or perforated, or have any other characteristic property that allows it to change shape. In some aspects, the flexible anchor 150 can be coated with biological or biocompatible coatings, and also can be soaked in platelets and other biologics, which can be easily absorbed by the flexible anchor 150. In one exemplary configuration, the flexible anchor 150 can be formed from a strand of No. 5 braided polyester suture. In other words, multiple fibers can be braided together to form a hollow braided suture having a longitudinal passage.

As shown for example in FIG. 5, a suture 170 can be passed through a first opening 174 in a wall of the flexible anchor 150, guided into and along the passage 162, and passed out of the passage 162 through a second opening 178 in a wall of the flexible anchor 150 to form a suture construct 184 having free ends 186 and 188. The openings 174, 178 can be positioned intermediately between the first and second ends 154, 158 of the flexible anchor 150 at a distance of, for example, one-quarter length from ends 154, 158. It will be appreciated that the openings 174, 178 can be apertures or voids in the woven fabric of the flexible anchor 150, such that the openings 174, 178 do not disrupt or break the weave of the flexible anchor 150 when made of braided or woven material. Further, portions of the flexible anchor 150 between the first and second ends 154, 158 and the corresponding first and second openings 174, 178, can define anchoring leg or tail portions 190 that can provide additional resistance for securing the flexible anchor 150 relative to the bone, as will be discussed in greater detail herein. In one exemplary configuration, suture 170 can pass only through openings 174, 178 and a portion of the passage 162 extending therebetween to form a loop that does not extend through tail portions 190.

Suture construct 184 can be loaded onto inserter 86 by coupling flexible anchor 150 to the forked configuration 148, as shown in FIG. 4. First and second portions 192, 196 of suture construct 184 can be routed along elongate member 94 and into longitudinal channel 112. Suture portions 192, 196 can then be routed into protrusion 118 via slot 126 and secured thereto with securing member 134, as also shown in FIG. 4. In one exemplary configuration, free ends 186, 188 of suture portions 192, 196 can extend from protrusion 118.

With suture construct 184 coupled to inserter 86, the elongate member 94 of inserter 86 can be inserted into guide 30 to position flexible anchor 150 in prepared bore 78, as shown in FIGS. 6, 7 and 8. The flexible anchor 150 can include a first profile or shape 224 that allows for insertion through guide 30 and into prepared bore 78. A mallet or other impacting instrument 200, as shown in FIG. 6, can be used to impact the first end 98 of inserter 86 to fully seat flexible anchor 150 in bore 78, as shown in FIG. 8. In one exemplary configuration, the elongate member 94 of inserter 86 can include a specific length 204, as indicated in FIG. 4, calibrated to a length of guide 30 and drill bit 70 such that a user can advance the inserter 86 until the second end 104 of the inserter handle 90 contacts the first end 46 of guide member handle 34, as shown in FIG. 7. Alternatively, the user can observe the sight window 58 to determine initial placement of the soft anchor in bore 78, as also shown in FIG. 8.

With the flexible anchor fully seated in bore 78, as shown in FIG. 8, the inserter 86 can be slightly moved or withdrawn in an axial direction relative to bore 78 to deploy the flexible anchor 150 from the elongate member 94 of inserter 86, as shown in FIGS. 9A and 9B. During the axial translation, the tail portions 190 can facilitate frictional engagement with sidewalls 210 of bore 78 to aid in deploying flexible anchor 150 from inserter 86. Upon deployment of flexible anchor 150, the securing member 134 can be removed from protrusion 118 and the suture portions 192, 196 can be released from inserter handle 90, as shown in FIG. 10. Inserter 86 can then be removed from guide 30 and guide 30 can be removed from its position of contact with glenoid surface 26, as shown in FIG. 11. It should be appreciated that inserter 86 and guide 30 can be removed separately as discussed above or, in the alternative, can be removed simultaneously.

As shown in FIG. 11, the free ends 186, 188 of suture construct 184 can be pulled in a direction that is generally coaxial with and away from bore 78 to thereby set the flexible anchor 150 in an anchoring configuration relative to a cortical bone layer 218 of the glenoid 14. In one exemplary configuration, during setting of flexible anchor 150, portions of the anchor, including tail portions 190, can bunch together, collapse, expand and/or change shape to a second shape, configuration or locking profile 226 to form an anchoring mass 228, as shown in FIG. 11. Anchoring mass 228 can then be set or seated against an inner face of cortical bone layer 218 surrounding bore 78. In an exemplary configuration, second shape or profile 226 can include a width that is greater than that of first profile 224 and that of the initially formed bore 78 such that portions of flexible anchor 150 can expand into the cancellous bone layer 222 and extend transversely beyond the width or diameter of bore 78 beneath the cortical bone 218. For example, the anchoring mass 228 can include a width in a direction perpendicular to a longitudinal axis of bore 78 greater than the width of first profile 224 and the width of initially formed bore 78. In an exemplary configuration, the flexible anchor 150 can lock against a ledge 232 of cortical bone layer 218, as shown in FIG. 11.

In one exemplary configuration, flexible anchor 150 can include an outer diameter of 1.4 mm in cross-section and can be inserted and set into a 1.4 mm diameter bore 78. With the flexible anchor 150 folded about an axis transverse thereto and coupled approximately mid-length to forked configuration 148 of distal tip 146 of inserter elongate member 94, a slight impacting action on inserter instrument 86 may be required to fully insert anchor 150 in bore 78, as discussed above. Flexible anchor 150 can provide pull-out strength at least equivalent to that of conventional non-suture formed hard anchors that require a significantly larger bore in the bone. For example, flexible anchor 150 having a 1.4 mm diameter and being formed of polyester suture can have an equivalent or greater pull-out force than a conventional hard anchor having a 3 mm diameter and being formed of PEEK, based on static load testing. Thus, it can be seen that flexible anchor 150 provides fixation strength comparable to larger, hard bone anchors while requiring significantly less bone disruption. The flexible nature and smaller size of flexible anchor 150, combined with the corresponding smaller size of bone hole 78, provides an ability to use the suture construct 184 in a less invasive manner as well as in areas of the anatomy where the larger, hard anchors cannot be used. It should be appreciated that flexible anchors of varying diameters or widths in cross section can be used, including diameters or widths within a range of 0.3 mm to 3.0 mm, or greater.

With reference to FIG. 12, once the anchor has been set, as discussed above, a sliding knot 230 can be formed to secure the portion of the labrum 18 associated with labral tear 22 to the glenoid 14. In this regard, it will be appreciated that the suture 170 can slide relative to the set anchor 150 in the set configuration of FIG. 11, so as to tightly secure the sliding knot against the labrum, as shown in FIG. 11. In other words, each end 186, 188 of the suture 170 can be moved or slid relative to the set anchor 150. The sliding knot 230 can be formed with one free end 186, 188 knotted about the opposing leg of suture 170 and the other free end 188, 186 of the opposing leg of suture 170 can be pulled or tightened to tightly secure the sliding knot 230 against the labrum 18, as shown in FIG. 12 with reference to FIG. 5. In one exemplary configuration, the free ends of suture 170 can be passed around lateral sides 234 (FIG. 20) of labrum 18 and then the sliding knot 230 can be tied and the suture 170 can be tensioned to tightly secure labrum 18 to glenoid 14 at the area of the prepared bone 26 shown in FIG. 2. In another exemplary configuration, one free end of suture 170 can be passed through a portion of the labrum proximate glenoid surface 26 and the other free end can be passed around a lateral side of the labrum 18. The sliding knot 230 can then be formed and the suture 170 can be tightened to secure labrum 18 to glenoid 14.

Turning now to FIGS. 13-19, exemplary alternative suture constructs and an associated alternative inserter will now be discussed. With particular reference to FIG. 13, a preformed adjustable self-locking suture construct 250 is provided according to the present teachings and can include a braided suture 254 having a first end 258 and a second end 262, and can include a body 264 that defines a longitudinal passage portion 268 therein between first and second ends 258, 262, as shown in FIG. 13. The passage portion 268 can define a pair of apertures 272, 276 at opposed ends thereof. To form construct 250, the first end 258 can be passed through aperture 272 and passage portion 268 and out aperture 276 such that a portion 280 of suture 254 following first end 258 extends through passage portion 268. In a similar manner, second end 262 can be passed through aperture 276 and passage portion 268 and out aperture 272 such that a portion 284 of suture 254 following second end 262 also extends through passage portion 268. This configuration forms two loops 288 and 288′, as shown in FIG. 13. It should be appreciated that while passage portion 268 is shown having two apertures or openings 272, 276, passage portion 268 can have additional openings and/or can include additional passage portions.

The pulling or tensioning of ends 258, 262 can cause reciprocal movement of portions 280, 284 relative to passage portion 268, and the loops 288, 288′ can be reduced to a desired size placed in a desired tension. Tension in loops 288, 288′ can cause the body 264 defining the passage portion 268 to be placed in tension and therefore cause passage portion 268 to constrict about portions 280, 284 passed therethrough. This constriction reduces the diameter of passage portion 268, thus forming a mechanical interface between the exterior surfaces of portions 280, 284 and an interior surface of passage portion 268. This constriction results in static friction between the interior and exterior surfaces at the mechanical interface, causing the adjustable suture construct 250 to “automatically” lock in a reduced size or diameter configuration in which tension is maintained without use of a knot. Adjustable suture construct 250 can include a pair of flexible anchors 150 coupled to loops 288, 288′ in a similar manner as discussed above with respect to suture construct 184. Suture construct 250 with adjustable loops 288, 288′ can be used to secure the labral tear 22 and/or in other procedures such as a facelift, as will be discussed herein.

With reference to FIG. 14 and continuing reference to FIG. 13, an alternative preformed adjustable self-locking suture construct 300 is shown. Construct 300 can be preformed to include a double loop configuration having two loops 304, 304′ that each traverse a path from one end of passage portion 268 to the other end thereof, instead of each loop being disposed at respective opposite ends of passage portion 268 as in construct 250. Suture construct 300 can be formed by passing the first end 258 of the suture through aperture 276, through passage portion 268 and out aperture 272. The second end 262 can be passed through aperture 272, through the passage portion 268 and out the aperture 276. In various aspects, the first and second apertures 272, 276 can be formed during the braiding process as loose portions between pairs of fibers defining the suture 254, as discussed above.

Passing ends 258, 262 through the apertures 272, 276 can form the loops 304, 304′. The loops 304, 304′ can define mount or summit portions 308, 308′ of the adjustable suture construct 300 and can be disposed generally opposite from the passage portion 268. Adjustable suture construct 300 can include a pair of flexible anchors 150, as shown in FIG. 14. One flexible anchor 150 can be coupled to the summit portions 308, 308′ of loops 304, 304′ such that both loops 304, 304′ extend the respective flexible anchor 150 in a similar manner as discussed above with respect to suture construct 184. The other flexible anchor can be coupled to passage portion 268 such that passage portion 268 extends through the flexible anchor 150 in a similar manner as discussed above. Suture construct 300 can also be used, for example, to secure the labral tear 22 and/or in other procedures such as a facelift, as will be discussed herein.

The longitudinal and parallel placement of the first and second ends 258 and 262 of the suture 254 within the passage portion 268 resists the reverse relative movement of the first and second portions 280, 284 of the suture construct 300 once it is tightened. The tensioning of the ends 258 and 262 can cause reciprocal movement of the portions 280, 284 relative to passage portion 268. Upon applying tension to the first and second ends 258 and 262, the loops 304, 304′ can be reduced to a desired size or placed in a desired tension. Tension in the loops 304, 304′ can cause the body of the suture 254 defining the passage portion 268 to be placed in tension and therefore cause passage portion 268 to constrict about the portions 280, 284 similarly to the constriction discussed above with respect to construct 250. This constriction can cause the adjustable suture construct 300 to “automatically” lock in a reduced size or smaller diameter configuration.

Turning now to FIG. 15, an exemplary adjustable self-locking suture construct 300A is provided having only one loop 304′. Adjustable suture construct 300A can be preformed in a similar manner as construct 300, but with only one loop. Suture construct 300A can include a pair of flexible anchors 150 coupled thereto in a similar manner as discussed above. A further discussion of the suture constructs 250, 300 and 300A are provided in U.S. patent Ser. No. 11/541,506 filed on Sep. 29, 2006 entitled “Method and Apparatus for Forming a Self-Locking Adjustable Suture Loop” assigned to Biomet Sports Medicine, LLC, the disclosure of which is incorporated herein by reference.

Referring now to FIGS. 16-19, an exemplary inserter instrument 350 is provided in accordance with the present teachings and can include a pair of inserters 354A and 354B removably coupled together, as shown in FIG. 16. In one exemplary configuration, each inserter can include the same features and thus the following discussion of the features of inserter 354A will be understood to apply to inserter 354B as well. Inserter 354A can include a handle 358 and an elongate member 362 extending therefrom, as shown in FIGS. 18 and 19. Handle 358 can include a first end 366, a second opposite end 370, a top surface 374, and lateral sides 378. First end 366 can include a female coupling arrangement 384 and second end 370 can include a male coupling arrangement 388. At least one lateral side 378 of handle 358 can include a longitudinal recess or channel 392 configured to receive the elongate member of inserter 354B when coupled thereto, as will be discussed below. Handle 358 can also include protrusion 118 extending from top surface 374 and securing member 134 configured to be coupled thereto, as shown in FIG. 17 and discussed above.

Elongate member 362 can include a first end 398 coupled to the second end of handle 358 and an opposite second end 402 forming a distal tip 406 of inserter 354A. Distal tip 406 can include a forked configuration 410 sized and shaped to receive a flexible anchor 150 similar to inserter 86 discussed above. Elongate member 362 can be coupled to handle 358 in a position laterally offset from a longitudinal center of handle 358, as shown in FIG. 18. Laterally offsetting elongate member 362 provides the ability to removably couple inserters 354A and 354B together in a co-axially aligned fashion, as shown in FIGS. 16 and 17.

To couple inserter 354B to inserter 354A, the second end 370 of handle 358 of inserter 354B can be placed proximate the first end 366 of handle 358 of inserter 354A. Inserter 354B can be orientated such that its longitudinal axis is parallel to the longitudinal axis of inserter 354A and the elongate member of inserter 354B is substantially aligned with the longitudinal channel of inserter 354A, as shown for example in FIGS. 16 and 17. The male coupling arrangement of 354B can then be coupled to the female coupling arrangement of inserter 354A such that the handles of inserters 354A and 354B abut each other and the elongate member 362 of inserter 354B is received in the longitudinal channel 392 of inserter 354A.

One of the exemplary preformed adjustable suture constructs 250, 300, 300A can be coupled to inserter 350 for use in an associated surgical procedure, as will be discussed below. It should be appreciated that other adjustable suture constructs, such as illustrated and disclosed in the applications incorporated by reference herein, can be used with inserter 86 or 350 in various surgical techniques. With particular reference to FIG. 17, one of the flexible anchors 150 can be coupled to the distal tip 406 of inserter 354A and the other flexible anchor can be coupled to the distal tip of inserter 354B. It should be appreciated that the suture constructs can be coupled to inserters 354A and 354B before or after inserters 354A and 354B are coupled together. The loop portions and ends of the suture construct can be routed in various configurations relative to inserters 354A and 354B to removable couple the respective suture construct thereto. In one exemplary configuration, suture construct 250 can be coupled to inserter 350, where the flexible anchor 150 of loop 288 can be coupled to the distal tip 406 of inserter 354A and the flexible anchor 150 of loop 288′ is coupled to the distal tip of inserter 354B. The remaining portions of the loops 288, 288′ as well as the ends 258, 262 can be coupled to one or both of the protrusions 118. In one exemplary configuration, loops 288, 288′ and free ends 258, 262 are coupled to the protrusion of inserter 354B so that the loops and free ends do not have to be decoupled from inserter 354A when inserter 354B is decoupled therefrom, as will be discussed in greater detail below.

Adjustable suture construct 300 can also be used with inserter 350 in a similar manner to adjustable suture construct 250 discussed above. As will be discussed in greater detail below, the flexible anchor 150 coupled to inserter 354A can be implanted into the anatomy before the flexible anchor 150 coupled to inserter 354B. In this regard, and in connection with adjustable suture construct 300, an associated surgical procedure can dictate which flexible anchor 150 should be coupled to each of inserters 354A and 354B. For example, in a surgical procedure where one of the flexible anchors 150 of construct 300 will be implanted into the bone and the other flexible anchor will engage an outer surface of soft tissue, such as the labrum 18, a determination will need to be made whether the flexible anchor 150 on the passage portion 268 will be implanted in the bone or be positioned relative to the outer surface of the soft tissue. If the flexible anchor 150 associated with passage portion 268 is desired to be implanted into the bone, then this flexible anchor 150 should be coupled to inserter 354A and flexible anchor 150 associated with summit portions 308, 308′ should be coupled to inserter 354B.

With additional reference to FIG. 20, an exemplary surgical technique for securing labral tear 22 or other soft tissue will now be described in greater detail in connection with inserter 350. A pair of bores 78 can be drilled into the glenoid bone 14 adjacent lateral sides of labrum 18 using a similar procedure as discussed above in FIGS. 1-12. Adjustable suture construct 250 can be coupled to inserter 350 as discussed above and the elongate member 362 of inserter 354A can be inserted into a first one of the bores 78 to deploy the flexible anchor 150 associated with loop 288 in the manner discussed above. It should be appreciated that inserter 350 can be used with or without guide 30. With the flexible anchor 150 associated with inserter 354A deployed, inserter 354B can be decoupled from inserter 354A in anticipation of implanting the flexible anchor associated with loop 288′ into the second one of the bores 78. If any portions of loops 288, 288′ or ends 258, 262 are coupled to the protrusion 118 of inserter 354A, such portions or ends can be released therefrom.

Inserter 354A can be removed from the immediate vicinity of the surgical area and the elongate member 362 of inserter 354B can be inserted into the second one of the bores 78 to position the flexible anchor 150 associated with loop 288′ therein. This flexible anchor can be deployed as discussed above and any suture loop portions and/or ends can be decoupled from the protrusion 118. Suture construct 250 can now be positioned such that the construct 250 spans around an exterior surface 418 with the passage portion positioned between the first and second bores 78, as shown in FIG. 20. Tension can be applied to each of the free ends 258, 262 to set the anchors (as discussed above) and secure the labrum 18 to the glenoid 14. It should be appreciated that while the free ends are being tensioned, portions of the loops 288, 288′ can slide relative to the set anchors as the self-locking adjustable suture construct 250 is tightly secured against labrum 18 without the use of a knot. In addition, while adjustable suture construct 250 is shown extending around labrum 18, it should be appreciated that portions of suture construct 250 can pierce through lateral sides 234 of labrum 18 proximate bores 78.

Turning now to FIG. 21, inserter 86 is shown having suture construct 300 coupled thereto in place of suture construct 184. In this exemplary configuration, flexible anchor 150 associated with passage portion 268 is coupled to the distal tip 146 of elongate member 94. The second flexible anchor 150 associated with summit portions 308, 308′ can extend freely from inserter 86, as shown in FIG. 21. The first and second ends 258, 262 of construct 300 extend along the elongate member 94 into channel 112 and can be secured to protrusion 118 with securing member 134.

With additional reference to FIGS. 21-23, exemplary surgical techniques will now be discussed in greater detail in connection with inserter 86 and suture construct 300 coupled thereto. With particular reference to FIG. 22, an alternative technique for repairing the labral tear 22 can include coupling adjustable suture construct 300 to inserter 350 such that the flexible anchor 150 associated with the passage portion 268 is coupled to the distal tip 146 of elongate member 94 and the other flexible anchor extends freely therefrom, as shown in FIG. 21. The elongate member 94 can then be inserted into and through labrum 18 and into bore 78 prepared in the manner discussed above. It should be appreciated that guide 30 can be used with elongate member 94, if desired. Inserter 86 can then be axially moved relative to bore 78 and labrum 18 to deploy anchor 150 associated with passage portion 268 into bore 78. Inserter 86 can then be removed from bore 78 and labrum 18, and suture ends 258, 262 can be decoupled from protrusion 118. Suture construct 300 can now be positioned such that the flexible anchor 150 associated with the passage portion 268 is positioned in bore 78 and portions of loops 304, 304′, as well as free ends 258, 262 extend from bore 78 and through labrum 18, as shown in FIG. 22.

The free ends 258, 262 extending from labrum 18 can be tensioned to reduce the size of loops 304, 304′ and set the flexible anchor 150 in bore 78 in the manner discussed above. Further tensioning of suture construct 300 can continue to reduce the size of loops 304, 304′ thereby compressing flexible anchor 150 associated with summit portions 308, 308′ against the exterior surface of labrum 18 and tightly securing labrum 18 against glenoid 14 with using a knot. It should be appreciated that during tensioning of suture construct 300, passage portion 268 and summit portions 308, 308′ slide relative to the respective flexible anchors 150. While the above surgical technique has been described in connection with implanting one suture construct 300, it should be appreciated that multiple suture constructs 300 and/or combinations of suture constructs 84, 250 and 300 can be used in the surgical technique.

Turing now to FIG. 23, an exemplary surgical technique for a facelift will now be described with reference to inserter 86 and suture constructs 250 and 300. In one exemplary configuration shown in FIG. 23, suture construct 250 can be modified so as to include only one flexible anchor 150 that is coupled to loop 288 while loop 288′ does not include a flexible anchor. The modified suture construct 250 can be coupled to inserter 86 in a similar manner as discussed above in connection with FIG. 21 such that flexible anchor 150 associated with loop 288 can be coupled to elongate member 94 loop 288′ can extend freely therefrom. At least one bore 78 can be prepared in a skull 438 of the patient similar to the preparation of bore 78 in glenoid 14. The elongate member 94 of inserter 86 can then be inserted into bore 78 to position flexible anchor 150 therein. It should be appreciated that elongate member 94 can be inserted into bore 78 with or without the use of guide 30 for this procedure.

Inserter 86 can then be translated relative to skull 438 to deploy flexible anchor 150 in a similar manner as discussed above. Once anchor 150 is deployed, inserter 86 can be removed from bore 78 and free ends 258, 262 can be decoupled from protrusion 118 and inserter 86. Loop 288′ can then be temporarily coupled to an appropriate position of the skin of the forehead 444 proximate the patient's hairline 448 with suture or other appropriate methods, as shown in FIG. 23. Once loops 288, 288′ are secured to the skull 438 and forehead skin 444, free ends can be tensioned to reduce the size of loops 288, 288′ to set anchor 150 and stretch the forehead skin 444 towards the bore 78 by any appropriate amount. It should be appreciated that anchor 150 can be set as described immediately above or before loops 288, 288′ ends 258, 262 are tensioned to reduce the size of loops 288, 288′. While the above surgical technique has been described in connection with implanting one suture construct 250, it should be appreciated that multiple suture constructs 250 and/or combinations of suture constructs 250 and 300 can be used in this surgical technique. While the above surgical technique has been described with reference to the forehead skin 444, it should be appreciated that other areas of facial skin can be coupled to loop 288′ to stretch or reconfigure the facial skin as discussed above with reference to the forehead skin.

While one or more specific examples have been described and illustrated, it will be understood by those skilled in the art that various changes may be made and equivalence may be substituted for elements thereof without departing from the scope of the present disclosure as defined in the claims. Furthermore, the mixing and matching of features, elements and/or functions between various examples may be expressly contemplated herein so that one skilled in the art would appreciate from the present disclosure that features, elements and/or functions of one example may be incorporated into another example as appropriate, unless described otherwise above. Moreover, many modifications may be made to adapt a particular situation or material to the present disclosure without departing from the essential scope thereof. 

What is claimed is:
 1. An assembly for securing soft tissue to bone, comprising: a flexible tubular anchor having a passage; and a flexible member construct having a body defining a passage portion between first and second ends, the first end being passed though a portion of the passage of the flexible tubular anchor spaced apart from respective ends of the flexible tubular anchor to form first and second flexible anchoring legs free of the flexible member, and the first end being passed into and through the passage portion via first and second openings associated with the passage portion to form at least one adjustable, self-locking loop; wherein the flexible tubular anchor is slidably coupled to the flexible member construct and is configured to be collapsible upon engagement with bone to form an anchoring mass having a locking profile.
 2. The assembly of claim 1, wherein the flexible member construct further comprises the first end being passed into the passage portion via the first opening and exiting the passage portion via the second opening to form a first adjustable, self-locking loop, and the second end being passed into and through the passage portion in a direction opposite the first end via entering through the second opening and exiting through the first opening to form a second adjustable self-locking loop.
 3. The assembly of claim 2, further comprising passing the second end through a portion of a passage of a second flexible tubular anchor to slidably couple the second flexible tubular anchor to the flexible member construct.
 4. The assembly of claim 3, further comprising an inserter instrument having first and second elongate members extending from respective first and second handles, the flexible anchor coupled to a distal tip of the first elongate member and the second flexible tubular anchor coupled to a distal tip of the second elongate member, the first and second handles being removable coupled to each other such that the first elongate member extends distally beyond the distal tip of the second elongate member.
 5. The assembly of claim 4, wherein each handle includes a proximal end and a distal end, the elongate members extending from the distal ends of the respective handles, wherein the first and second handles are removable coupled to each other such that the handles are substantially axially aligned with the distal end of the second handle removably engaging the proximal end of the first handle.
 6. The assembly of claim 5, wherein the proximal end of the first handle includes one of a male or female coupling member and the distal end of the second handle includes the other of the male or female coupling member.
 7. The assembly of claim 1, wherein the flexible member construct further comprises the first end being passed into the passage portion via the second opening and exiting the passage portion via the first opening to form a first adjustable, self-locking loop, and the second end being passed into and through the passage portion in a direction opposite the first end via entering through the first opening and exiting through the second opening to form a second adjustable, self-locking loop.
 8. The assembly of claim 7, further comprising passing the first and second ends through a portion of a passage of a second flexible tubular anchor to slidably couple the second flexible tubular anchor to the first and second loops; and wherein the flexible tubular anchor is slidably coupled to the passage portion of the flexible member construct.
 9. The assembly of claim 1, wherein the flexible tubular anchor is formed from woven or braided suture and includes first and second openings intermediate respective first and second ends, the first end of the flexible member construct being passed through the passage via the flexible anchor first and second openings; and wherein portions of the flexible tubular anchor between the first and second ends and the respective first and second openings define anchoring leg portions.
 10. The assembly of claim 1, further comprising an inserter instrument having an elongate member extending from a handle, the flexible tubular anchor being coupled to a distal tip of the elongate member and the flexible member construct being secured to a protrusion extending from the handle via a securing member removably coupled to the protrusion.
 11. An assembly for securing soft tissue to bone, comprising: a flexible member having an elongated body; and a flexible anchor having a passage extending from a first anchor end and a second anchor end; wherein the flexible anchor is coupled to the flexible member by a portion of the flexible member extending through first and second openings in the flexible anchor, where the portion extends from the first opening, continuously within the passage in a direction form the first anchor free end to the second anchor free end, and to the second opening, where a longitudinal cross-sectional plane extends through the flexible anchor and the first and second openings extend through the flexible anchor on a first side of the longitudinal cross-sectional plane, and the first and second openings are between and spaced apart from the first and second anchor free ends to form first and second flexible anchoring legs free of the flexible member.
 12. The assembly of claim 11, wherein the flexible anchor is a flexible tubular anchor.
 13. The assembly of claim 12, wherein the flexible member extends through the first opening along a portion of the passage and out the second opening to form the first and second flexible anchoring legs free of the flexible member.
 14. The assembly of claim 13, wherein the flexible member and the flexible anchor are each formed of hollow braided suture.
 15. The assembly of claim 12, wherein the flexible tubular anchor is configured to change shape from a first profile to a second profile to form an anchoring mass to retain the flexible tubular anchor in the bone.
 16. The assembly of claim 11, wherein the flexible member forms a flexible member construct having at least one adjustable, self-locking loop, wherein the flexible anchor is slidably coupled to the at least one adjustable, self-locking loop.
 17. The assembly of claim 16, wherein the body of the flexible member defines a passage portion and a first end of the flexible member extends into and through the passage portion via first and second openings associated with the passage portion to form the at least one adjustable, self-locking loop.
 18. The assembly of claim 17, wherein the flexible member construct further includes a second adjustable, self-locking loop and a second flexible anchor coupled to the second adjustable loop.
 19. The assembly of claim 11, further comprising an inserter instrument having an elongate member extending from a handle, the flexible anchor being coupled to a distal tip of the elongate member and the flexible member being secured to a protrusion extending from the handle via a securing member removably coupled to the protrusion.
 20. An assembly for securing soft tissue to bone, comprising: a flexible member having a body and configured to form at least one flexible, adjustable, self-locking loop; and a flexible anchor having a passage extending from a first anchor end to a second anchor end; wherein the flexible anchor is coupled to the at least one flexible, adjustable, self-locking loop by a portion of the at least one flexible, adjustable, self-locking loop passing through first and second openings in the flexible anchor, where the first and second openings are between and spaced apart from the first and second anchor ends to form first and second flexible anchoring legs free of the flexible member.
 21. The assembly of claim 20, wherein the flexible anchor is a flexible tubular anchor.
 22. The assembly of claim 21, wherein the flexible member extends through the first opening along a portion of the passage and out the second opening to form the first and second flexible anchoring legs free of the flexible member.
 23. The assembly of claim 22, wherein the flexible member and the flexible anchor are each formed of hollow braided suture.
 24. The assembly of claim 21, wherein the flexible tubular anchor is configured to change shape from a first profile to a second profile to form an anchoring mass to retain the flexible tubular anchor in the bone.
 25. The assembly of claim 20, wherein the body defines a passage portion between first and second ends where at least a portion of the flexible member passes through the passage portion via first and second openings associated with the passage portion to form the at least one flexible loop.
 26. The assembly of claim 20, wherein the at least one flexible loop is formed by passing the first end of the flexible member through a passage portion defined by the body to form the at least one flexible, adjustable, self-locking loop.
 27. The assembly of claim 20, further comprising an inserter instrument having an elongate member extending from a handle, the flexible anchor being coupled to a distal tip of the elongate member and the flexible member being secured to a protrusion extending from the handle via a securing member removably coupled to the protrusion. 